The Decline of Lobotomy

Introduction of drug treatments for schizophrenia

The widespread introduction of chlorpromazine in 1954 was associated with reduced rates of psychosurgery across the globe, and gave State Hospital staff a valuable new treatment for psychotic and agitated patients (See Figure 5). In New York State, in 1956 there were more discharges from hospital than the previous year, despite a greater number of admissions. The rate of readmission was reduced as well (Brill & Patton, 1957).

It is estimated that over 2 million people in the USA received chlorpromazine in the first year after its release (Feldman & Goodrich, 2001), and for the first time, there was an alternative to insulin coma, electroconvulsive therapy, and psychosurgery. Ironically, the effects of chlorpromazine on many patients were described in terms of reduced property destruction, improved behaviour, and satisfaction of relatives. Much of the structure that existed to assess the response to chlorpromazine in the state hospitals had been developed from, or had evolved from, experiences with psychosurgery (Pressman, 1998, p. 422). For example, the Inpatient Multidimensional Psychiatric Scale (IMPS), developed by Lorr in the early 1960s was used to assess symptom improvement in the NIMH collaborative study of Chlorpromazine (Guttmacher, 1964). The scale itself was developed to assess responses to psychosurgery a number of years previously.
Despite hopes, chlorpromazine was not perfect, and adverse effects were recognised within the first year or so (Cohen, 1956). Some patients who did not respond to the new medication still progressed to lobotomy as a treatment of last resort.

Public attitudes towards psychosurgery

During the 1950s, public antipathy to psychosurgery led to mounting socio-political pressure on psychiatrists and neurosurgeons to stop performing such procedures. The general public and a large, vocal proportion of the medical profession were vehemently opposed to such procedures. It is generally accepted that popular opinion led to a decline in psychosurgery but this is likely to be an oversimplification. In a review of magazine and newspaper articles from 1935 to 1960, Diefenbach et al (1999) found that from 1935 to 1944 articles were generally positive in their reporting of psychosurgery, often excessively so. However, from 1945-1954 reporting became more balanced and authors debated the risks associated with such procedures, which were being widely performed. In 1949, Egas Moniz received the Nobel Prize for Medicine for the development of leucotomy for psychosis. During this period the press became increasingly negative, beginning to criticise an apparent eagerness to perform surgery without key questions about safety and efficacy being asked.

Whilst much of the opposition to psychosurgery was critical of an absence of research detailing key outcomes, and the changes in personality and higher cognitive functions, many of the arguments took a rather ‘principled’ approach, accusing psychosurgery of irreversibly removing such attributes as “personal sovereignty” and “personal freedom” (Breggin, 1980). To better understand the opposition to psychosurgery that was developing, it is important to take into account a number of other factors (Sections 3.7.3 and 3.7.4).

Diagnostic Uncertainty

During the period when psychosurgery was in its heyday many of the patients who were in psychiatric institutions would probably have been unlikely to warrant admission to hospital in the UK today. Many patients who underwent psychosurgery weren’t even inpatients (Bernstein, Callahan & Jaranson, 1975). Furthermore, diagnosis was an inexact (and corruptible) science as David Rosenhan’s famous experiment, “On being sane in insane places” demonstrated (Rosenhan, 1973). During the 1970s, there were significant cross-national differences in the rates of diagnosis of schizophrenia. In the USA (New York) the rate of diagnosis was 65% whilst the rate in London was 34%, despite similar rates of admission and the fact that both countries were using the same classification system, ICD-8 (Cooper, Kendall, Gurland, et al, 1972). In the USA, many patients with mania, for example, would be diagnosed as schizophrenic and Gurland and colleagues went on to comment that, “New York hospital staffs tend to give a diagnosis of schizophrenia to the major proportion of every kind of patient group” (Gurland, Fleiss, Cooper, et al, 1970). The authors of the report also stated that, “there is a tendency in New York for most patients, other than those with organic or addictive states, to be regarded as schizophrenics regardless of their symptoms” (Cooper, Kendall, Gurland, et al, 1972). This is undoubtedly a rather damming assessment of the robustness of a diagnosis of schizophrenia in the USA. It is a reasonable conclusion, therefore, that:

A significant number of patients who underwent psychosurgery in the 1960s and 1970s probably did not have schizophrenia as we would recognise it now. A diagnosis of schizophrenia was a poor prognostic indicator following psychosurgery in the UK, but less so in the USA. This may have reflected the inclusion of other diagnoses (with a greater likelihood of good outcome) within the ‘schizophrenic’ category in the USA. The poor outcomes reported in the popular press and in various medical journals will reflect the effects of leucotomy on a heterogenous group of patients. Many patients received leucotomy because of a lack of response to other treatments, but the possibility of incorrect diagnosis is not mentioned as a cause of non-response in early reports of psychosurgical techniques. It is a noticeable point among most of the early literature on psychosurgery that the diagnosis was vague at best. Performing a retrospective diagnosis from early published reports is virtually impossible due to the lack of information given.

Reports of a diminution of personality, drive, and other higher-order functions are easier to understand if we assume that many subjects reported in the literature would have not had indications that we recognise now as appropriate for neurosurgical intervention. Indeed, it is likely that in the absence of chronic depression or OCD, the operation was performed on what we would recognise now as ‘normal brain’.

Due to uncertainties in the diagnosis, the rates of improvement in an individual’s condition would have been unpredictable and it would not have been safe to assume that an individual would have had an unremitting course. Rates of improvement following hospitalisation for schizophrenia ranged from 5% recovered (paranoid) to 20% recovered (catatonic) to 10% much improved (paranoid) to 21% much improved (simple) (Cheney & Drewry Jr., 1938). Other studies have found that in those cases with less than 6 months duration of illness, 34.5% were improved at 5-10 year follow-up (Rupp & Fletcher, 1940). Romano and Ebaugh (1938) found that 23% were improved although only one patient fulfilled criteria for remission/ recovery without defect.

Theories of psychiatric illness

By the end of the 19th Century, biological psychiatrists had explored the brain and nervous system in great detail but had failed to connect abnormal brain structure or function with psychiatric illness, with the only exception being neurosyphilis. Carl Wernicke (who was convinced that psychiatric disorders were caused by disturbances of the associative system) and Jean-Martin Charcot (who believed that hysteria was caused by traumatic experiences in those individuals with “degenerate” brains) had both been unsuccessful in their attempts to discover demonstrable abnormalities in the brains of their psychiatric patients. At the same time, Sigmund Freud was developing his ideas about the causes of mental illness. Freud was first read in the USA in the late 19th Century and first visited the USA in 1909. It wasn’t long before his ideas were becoming popular and the American psychoanalytical movement sprang up within a few years of his visit to the USA. State hospitals were typically large, depressing buildings overflowing with patients for whom there was little treatment, and therapeutic nihilism among staff was undoubtedly widespread. The prospect of being able to take the practice of psychiatry to private offices in the community was appealing to many US psychiatrists, and the potentially lucrative nature of private psychoanalysis would have been attractive